Healthcare Provider Details

I. General information

NPI: 1861629172
Provider Name (Legal Business Name): HENRY JOEL MROCZKOWSKI MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST
MEMPHIS TN
38105
US

IV. Provider business mailing address

49 N DUNLAP ST FACULTY OFFICE BUILDING - 144
MEMPHIS TN
38103-2802
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-6465
  • Fax:
Mailing address:
  • Phone: 901-448-6491
  • Fax: 901-448-4117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD444907
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53440
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-7267
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number53440
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD444907
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberE-7267
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: